Mental Capacity (Amendment) Bill [Lords]

Dan Poulter Excerpts

3rd reading: House of Commons & Report stage: House of Commons
Tuesday 12th February 2019 Commons Chamber

[Chris Bryant]

Absolutely. One key thing that we saw repeatedly—this is an issue for the Bill, I think—was the fluctuating nature of some brain injuries. For instance, fatigue is a very common feature of many brain injuries. I do not mean just feeling tired because you are sitting at the back of a debate in the House of Commons and somebody is wittering on for far too long and you fall asleep, but real, genuine fatigue. I mean the kind of lassitude that leaves you unable to move from one side of the bed to the other. It is often misunderstood, because it might look like laziness to somebody with a judgmental eye. That lassitude can pass or go through phases and can sometimes be a bit difficult to explain or predict. I am therefore really keen that we ensure, in all the processes in the Bill, that anyone with an acquired brain injury is regularly and repeatedly reassessed so that they have an opportunity to escape. That is important.

[Dr Dan Poulter (Central Suffolk and North Ipswich) (Con)]

The hon. Gentleman is making some good points. The only point I would make to him is that without a deprivation of liberty order—I agree that they should be open to review, and I am sure the Minister will go on to talk about how that can happen—some of the people he talks about may have to be put under the Mental Health Act 2007 due to the fluctuating nature of their capacity. That would be much more restrictive and could lead to them being sent to entirely the wrong places to be cared for. I would just give that caveat and that warning to him about the potential consequences of what he is saying.

[Chris Bryant]

I think the hon. Gentleman has just read, in some weird way, what I was about to say—he has a very special mental capacity of his own if he is able to read my notes from that distance. He is absolutely right, however, and I do not want to drive a coach and horses through the Bill at all. I fully accept that there is a requirement for some elements of it.

I have an anxiety about the pace at which the Bill is going. It is a shame that the code is not yet available, because it would significantly affect how we viewed some of the issues that we are talking about today. All the things in my amendments should probably be in the code, rather than on the face of the Bill—that is what the Minister said to me yesterday, and I should have given her a much harder time, by the way—but why do we not have the code now? We are not going to have it before the Bill receives its Third Reading, and I think that is a mistake. It is not as though we have lots of wonderful business to be getting through.

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[Barbara Keeley]

It is not helpful if the Minister and I argue about this. We have had this argument enough times in Committee. She just needs to see that there is a level of concern. I am quoting a case where significant harm was done to a young person in a care home because the parents were not listened to and the care staff were.

[Dr Poulter]

I can understand where the hon. Lady’s concerns come from, but having had detailed discussions with my hon. Friend the Minister, I am reassured, perhaps more than the hon. Lady, by the systems and some of the amendments that have been put in place to take into consideration concerns about conflicting provider interest. She makes a good point on the lack of funds and resources and cash-strapped local authorities. Without the money to support local authorities, there is a real risk that scrutiny of care homes and the processes in place under the legislation will be sadly lacking, to the detriment of people under deprivation of liberty orders. What reassurance has she had, if any, during the passage of the Bill that the funding crisis affecting social care and local authorities is being addressed by the Government, both in respect of this legislation and otherwise?

[Barbara Keeley]

I thank the hon. Gentleman for that question. We have had no reassurances whatever. In fact, since the Committee finished, £1.3 billion has been taken out of central Government funding to local councils. Whatever our position was when we were in Committee, things are now much, much worse.

The Minister does not agree, but it is disturbing that we are still in the position on Report of trading the arguments back and forth. We gave lots of examples. There is provision in the Bill for an approved mental capacity professional. With our amendment we want to be sure that we do not have cash-strapped local councils delegating responsibility. There is talk under some amendments to bring in reviews, but reviewers have to be able and willing to stand up to care home managers, and that is a difficult thing.

As my hon. Friend the Member for Bridgend (Mrs Moon) said earlier, care home managers have a lot of power. They have the power to evict and the power to stop visits. Amendment 49 would work with amendment 50 to address the role that the care home manager could play. It is one of the most concerning provisions in the Bill, and it must be addressed if the new liberty protection safeguards are to be fit for purpose.

I do not in any way want to stigmatise care home managers, but I ask Government Members to accept that we are talking about a situation where at least 20% of care homes require improvement or are rated inadequate. Care home manager vacancies are at 11%. We are not talking about a situation where all care homes have a proper care home manager in place, or where they are all doing as well as they could. If the Minister reads many CQC reports, she will see that care homes often fall down on care planning. CQC inspectors often find that there is not a proper or adequate care plan for the situation.

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[Caroline Dinenage]

I beg to move, That the Bill be now read the Third time.

Our liberty is the most fundamental of our human rights. By passing this Bill, we can be proud that we have helped to promote the human rights of our country’s most vulnerable people and increased access to protections for the 125,000 individuals who are being deprived of their liberty and are not receiving the safeguards they deserve. That means 125,000 people whose families do not have the peace of mind that their loved ones are being protected, and 125,000 care providers who do not have the requisite legal protection.

Members of both Houses have contributed to the discussions and debates on this Bill, for which I am extremely grateful. We have made changes in both Houses to ensure that the liberty protection safeguards system introduced by the Bill does everything possible to protect human rights—to give a voice to the person and those close to them—while also ensuring that the system is targeted and not cumbersome to people, their families and our health and care sector. I committed from the outset that we would collaborate on this Bill, listen and take on board all the ideas and feelings of stakeholders and Members from both Houses, and many of the amendments we have put forward today are exactly in that collaborative spirit.

[Dr Poulter]

I thank my hon. Friend for the conciliatory way in which she has gone about dealing with this Bill, engaging with colleagues on both sides of the Houses, and putting forward some good and sound amendments to get the Bill to a better place. However, on the issue of funding, which was raised during the debate earlier, if we are going to make social care legislation or legislation of this sort appropriate and have the right safeguards in place, we need local authorities to have a better funding settlement. Is that something she can take away and raise with the Secretary of State for Housing, Communities and Local Government?

[Caroline Dinenage]

My hon. Friend raises a very important point. I am grateful to him for all his feedback on this Bill, because it is very helpful to be able to speak to somebody from a medical background to understand how such a Bill will work in practice at the sharp end. We have given councils access to £10 billion over this three-year period, which just shows the scale of the issues we are facing in adult social care. The Green Paper that will be published shortly will go further in setting out the long-term sustainability of the sector.

As we have heard today, there is no question but that the current DoLS system is failing. In 2014, a House of Lords Committee identified the system as being complex and bureaucratic, and since then the situation has only got worse. An increased number of cases means that local authorities are unable to process all the applications. With more than 48,000 people now waiting over a year, we cannot risk people being subject to overly restrictive health and care practices. This new system will enable quicker access to safeguards, meaning that we can ensure less restrictive practices are being used.

The Government tasked the Law Commission with reviewing the DoLS system and recommending improvements. After more than three years of careful work and consultation, it published its report, which stated the urgent need for reform. That was followed by a report from the Joint Committee on Human Rights, which also recommended having a more targeted system by focusing resources on those who are the most vulnerable or those who have the most complex circumstances, and on cases where objections have been raised. Coupled with this, we have ensured robust safeguards in the system, including independent review and oversight, alongside access to representation and support.

I am grateful to all our partners who have worked with us on this Bill. The input of third sector groups, those who work in the health and care sector and of course those who receive safeguards themselves has all helped to shape our Bill for the better. The Law Commission was absolutely right when it said that DoLS needed to be replaced as a matter of urgency, and that is why we have brought this legislation forward now. We cannot continue with the current system. We are proud to bring forward the Law Commission’s recommendations in this Bill, and we are proud to reform the system and introduce a less bureaucratic, more personalised approach that will work better for people, their families and professionals. I commend this Bill to the House.

Mental Capacity (Amendment) Bill [Lords]

Dan Poulter Excerpts

2nd reading: House of Commons & Money resolution: House of Commons & Programme motion: House of Commons & Ways and Means resolution: House of Commons
Tuesday 18th December 2018 Commons Chamber

[Barbara Keeley]

The Minister says no, but Lord O’Shaughnessy in the House of Lords would not consider amendments tabled by two parties to deal with that issue. It is plainly wrong and represents a very clear conflict of interest.

Moreover, the Bill currently allows for the deprivation of someone’s liberty to be authorised for up to three years without review after two initial periods of 12 months, as the Secretary of State said earlier. It cannot be right to have that period of three years without renewal. The Bill is reducing the protections afforded by the current DoLS system, which operates a maximum period of 12 months before renewal.

[Dr Dan Poulter (Central Suffolk and North Ipswich) (Con)]

The hon. Lady is outlining, with some good reason, the fact that there may be fewer safeguards and fewer opportunities for people to review or appeal under this Bill than when someone is sectioned under the Mental Health Act. She has a point about the need to look into that point, and to look more broadly at how this Bill sits alongside the Mental Health Act, given Simon Wessely’s review. Does she agree that a pause would be helpful to consider the interface of those pieces of legislation?

[Barbara Keeley]

Very much so. I will come on to that shortly, but I will not leave the point about independent hospitals, because it is important.

We know only too well from media reports, and the Secretary of State does too, of the torrid situation in independent hospitals that detain people with autism and learning disabilities under the Mental Health Act, and the measures in this Bill could have disastrous and far-reaching consequences. I have raised at the Dispatch Box on several occasions the appalling treatment of people with autism and learning disabilities in assessment and treatment units. I have described the situation as amounting to a national scandal, and I believe that it is still so. As many as 20% of people in these units have been there for more than 10 years. The average stay is five and a half years. The average cost of a placement in an assessment and treatment unit for people with a learning disability is £3,500 a week, but the costs can be as high as £13,000 a week or more.

As the journalist Ian Birrell has exposed in The Mail on Sunday, private sector companies are making enormous profits from admitting people to those units and keeping them there for long periods. Two giant US healthcare companies, a global private equity group, a Guernsey-based hedge fund, two British firms and a major charity are among the beneficiaries of what campaigners have seen as patients being seen as cash cows to be milked by a flawed system at the expense of taxpayers. According to a written answer I obtained from the Department of Health and Social Care, in the past year alone the NHS has paid out over £100 million to private companies for these placements. Shamefully, the Government cannot reveal how much they have spent since they came to power, because they claim that they did not record the expenditure before 2017. It cannot be right that the Bill potentially gives private companies the power to lock up vulnerable people for years at a time to feed a lucrative and expanding private health sector.

I would like to draw attention to one more issue that the Bill does not address—we have already discussed it—and that cannot be papered over by amendments. The Government commissioned Professor Sir Simon Wessely to lead a review of the Mental Health Act, which is of course long overdue for reform. However, as the hon. Member for Central Suffolk and North Ipswich (Dr Poulter) said, there is clearly a complex interface between the Mental Capacity Act and the Mental Health Act. Professor Sir Simon Wessely has made the point that there is now a worrying trend of people, particularly with dementia, being detained under the Mental Health Act when their deprivation of liberty should be dealt with under the Mental Capacity Act. His review recommended imposing a new line of objection to determine who should be treated under which legislation, but, as the hon. Gentleman said, there has been no engagement with these recommendations, which were finalised as this Bill was going through the House of Lords.

In our view, the Government must commit to a review of the interface between the two Acts, with full consultation, which has, to date, been sorely lacking. It is one thing to say that Sir Simon had a conversation with the Secretary of State about this, but that is not full consultation. The consultation must look at both hospital and community settings and provide clear and accessible rights of appeal.

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[Alex Cunningham]

That is not something that has previously come to my attention, but I am sure the organisation would very much like to look at that possibility.

Following on from that, there must be a suitably qualified person carrying out the assessments and they must also be independent. A skilled approved mental capacity professional should be involved before a person is placed in an institution, not just when there is an objection or a trigger. There needs to be further clarity on the role of independent mental capacity advocates. Considering that the Bill in its current draft would allow responsible bodies to detain someone without renewal for up to three years, leaving people deprived of their liberty for inappropriate lengths of time, it is essential that there is genuine independence when it comes to such an assessment.

[Dr Poulter]

The hon. Gentleman is making some very good points. I am sure he is aware that, for a section 2 or section 3 admission to be approved under the Mental Health Act, there needs to be a second-opinion doctor—it is good practice for that doctor to be independent—and a social worker to ensure that the section admission takes place. It therefore seems extraordinary to me that, in a similar situation where there is an issue of capacity to be decided, there is not the safeguard of a second opinion, given that the decision may last for three years.

[Alex Cunningham]

I would certainly bow to the expertise of the good doctor and acknowledge exactly what the hon. Gentleman says. These second opinions and safeguards are absolutely essential, and I do not see such cover in the Bill at the moment.

Another concern I want to highlight is the lack of consultation and clarity about extending the scheme to 16 and 17-years-olds, and the risk that the new scheme will make it easier for authorities to remove young people from the care of their families, despite the family objecting. The Government must go back and give careful thought and consideration to the risk that 16 and 17-year-olds could see their liberty restricted inappropriately.

This issue has already been mentioned, but I too am concerned about the fact that there is no real acknowledgement of the interface between the Mental Capacity Act and the Mental Health Act, although the Secretary of State said it would be considered. I am no expert in this area, but does the Minister not agree that, as the Wessely review on the Mental Health Act has only just been published, the Government should pause the Bill to look at its recommendations properly, rather than risk creating legislation that does not fit together? Professionals must be able to understand the differences in regime and to clearly decide which is most appropriate.

We are dealing with changes to the law that any of our relatives, or even ourselves, could be subjected to in the future. We cannot just bounce this through the Commons and potentially hand substandard powers to a group of people who could rule the roost over an older person, a middle-aged person or a teenager, with nothing at all that their families could do about it.

There are plenty of people out there who are experts in this field; they could have been consulted and heard if there had been pre-legislative scrutiny of the Bill. I have some questions and concerns that have been raised by some of the organisations out there. From Inclusion London: does the Minister agree that the Bill makes it clear that deprivation of liberty cannot be used as a way to deliver care in the cheapest way possible? From the Royal College of Psychiatrists: can the Minister confirm that the Bill will not prevent psychiatrists from being called away from frontline services? From Mencap: what reassurances can the Minister give that all conflict of interest is removed from the Bill? There is plenty in there. From the Law Society: will the Government consider the interaction between the Bill and the Mental Health Act, as set out in their recently published review? Will they take the time to do that properly?

There are many other questions from many other organisations, and I hope that we have real time to address them if the Bill gets into Committee. I gather that the programme motion suggests that the Bill should come back towards the end of January, and there will not be a lot of time in January to consider the real issues. I just hope that the Minister will listen to that point.

NHS: Staffing Levels

Dan Poulter Excerpts

Tuesday 11th December 2018 Westminster Hall

[Dr Dan Poulter (Central Suffolk and North Ipswich) (Con)]

I congratulate the hon. Member for Batley and Spen (Tracy Brabin) on securing this debate and on highlighting the biggest challenge facing the NHS: the creeping workforce crisis that has been evolving for some time now. We are now seeing that crisis beginning, in real terms, to affect patient care.

The hon. Lady was right to highlight the fact that a lack of staff in some parts of the country means that operations are being cancelled and beds are being closed. She was also right to point out the challenges that Brexit poses to the recruitment and retention of frontline NHS staff; in the past decade, we have been increasingly reliant on European Union staff coming to work in the UK—before that, it was staff from outside the EU who provided most of the overseas workforce in the NHS. I am sure that all of us would like to put on the record our support for the excellent work that NHS staff from the UK and from all over the world do in caring for patients.

I will also do what I should have done at the beginning of my speech and draw attention to my declaration in the Register of Members’ Financial Interests, as I am a practising NHS hospital doctor working in mental health services.

[Paula Sherriff]

Will the hon. Gentleman give way on that point?

[Dr Poulter]

I will not, because of the time limit and because I want to let other people speak; I am sure that we can talk about this issue in detail after the debate.

Very briefly, Mr Hollobone, the Government have made a number of promises about NHS staffing and yet, unfortunately, those promises are failing to come to fruition. In 2015, there was a promise of 5,000 more GPs. Recently, I submitted a written parliamentary question about how much progress had been made in realising that target but I did not get an adequate answer. I would be grateful if the Minister updated us in his concluding remarks by saying how close we are to realising that target of 5,000 additional full-time GPs.

I would also like to highlight some of the challenges in community and mental health services. Very often in this Chamber, we talk about hospitals, and very often the NHS is seen through the prism of that acute sector, but the key challenge to keeping people out of hospital is doing more in the community, building up community mental and physical health services—and they are the very services that are seeing reductions in frontline staff.

I want to touch briefly on mental health. We know that the number of full-time-equivalent mental health nurses fell by 6,000 between 2010 and March 2018, including a reduction of more than 1,800 in learning disability nurses alone. The number of child and adolescent mental health service and learning disability consultant psychiatrists has also slightly declined over the past decade, and many parts of the country, particularly outside London, are struggling to fill higher registrar training posts in those services.

Perhaps more concerning is that the number of junior doctors in specialist psychiatry training—core and higher psychiatric trainees who will become the consultant psychiatrists of tomorrow—has also fallen, by 490 full-time equivalent doctors, from 3,187 in 2009 to 2,697 in March 2018. [Interruption.] The civil servants are rapidly checking my figures; they are from answers to parliamentary questions, so they are absolutely correct.

That is a woeful record of decline in the psychiatric and mental health workforce, and it must be corrected. If the Government are serious about their rhetoric on mental health, about improving the quality of provision for people with poor mental health, they need to recognise that the workforce has already declined. Even if there is the promised increase in numbers, it will be from a lower baseline than that of about a decade ago.

The only way to deliver the expansion in services that patients deserve—for example, specialist eating disorder services in Cumbria or East Anglia—is by having a much more serious approach to the recruitment and retention of mental health staff and by paying premiums to attract both doctors to work in CAMHS and people to work in parts of the country where there is a shortage of mental health staff. I look forward to the Minister’s response.

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[Dr Philippa Whitford (Central Ayrshire) (SNP)]

It is an honour to serve under your chairmanship, Mr Hollobone. I, too, declare an interest as a longstanding NHS worker of more than 30 years.

Healthcare is not delivered by machines or buildings; it is delivered by people. People are the core of the NHS. The problem relates to workforce, and it is hitting all four nations. Although Scotland has the highest ratio of every group of healthcare staff per head of population, we too face challenges. We have a 4.8% nurse vacancy rate in Scotland, but in England it is more than 11.5%. The Royal College of Nursing says that there are 41,000 nurse vacancies at the moment, and if action is not taken, that will rise to 48,000.

As other Members mentioned, since the introduction of the bursary in 2015, there has been a one third drop in applications. Acceptances in England have gone down by almost 4%, whereas in Scotland they have gone up by almost 14.5% over the same period. The bursary is having a huge impact, particularly on mature students, who might already have a degree and have therefore also been hit by the removal of the post graduate bursary that allows a nurse to be trained in just two years.

There has been a 15% drop in mature students, which is hitting those with mental health issues and learning disabilities in particular, as those specialities tend to attract the more mature nurse student. There has been a 13% drop in mental health nursing staff and a 40% drop in nurses looking after those with learning disabilities. That makes those services unsustainable.

Brexit is affecting the workforce, as it is every other aspect of life. There has been a 90% drop in European nurses registering to come and work in the UK, and a trebling of EU nurses who are leaving the UK register. That does not help to solve the problem, and those nurses cannot be totally replaced by UK staff in enough time. It does not matter that the Government come out with warm words if the Home Office’s actions make people feel insecure. Friends of ours who have been GPs for more than 20 years in Scotland applied for citizenship for their children. The eldest and youngest children were granted it; the middle child was refused. What are they now talking about? “Maybe we should go back to Germany where we’d be safe.”

From every angle, the Government are taking actions that are making staffing levels worse. The former Secretary of State for Health, the right hon. Member for South West Surrey (Mr Hunt), used to go on about the lack of junior doctors and consultants as a cause of excess deaths among those admitted at weekends. Actually, the only staffing impact proven through research is on the ratio of registered nurses to patients—not healthcare assistants or others.

[Dr Poulter]

I am sure that most of us had great concerns about the previous Secretary of State’s use of statistics, but a mental health study was carried out and the highest morbidity rates were in the middle of the week, not at weekends, which rather disproved the assertions that he was making.

[Dr Whitford]

We pointed that out repeatedly at the time. It has been shown time and again that quality, well-trained, experienced nurses—not so much agency nurses or healthcare assistants—who know a ward are the bedrock of every single service in healthcare.

Brexit is having an impact. Even though in Scotland our Government have promised to pay settled status fees for all those working in public services, we have already lost, according to the British Medical Association survey, 14% of our doctors. England has lost almost 20%. We cannot reach a point where England has 50,000 nurse vacancies. That would be unsafe. The Government need to take action and, like the Scottish Government, put the bursary back, get rid of tuition fees, and make it sustainable for people to train to become nurses. If they do not do that, the sustainability and safety of the NHS in England will deteriorate further.

Social Care Funding

Dan Poulter Excerpts

Wednesday 17th October 2018 Commons Chamber

[Matt Hancock]

I pay tribute to my right hon. Friend’s work in this area. He is incredibly thoughtful and has been prepared to ask some of the difficult questions and give his answers to them. I agree that this is something that we should take forward on a cross-party basis wherever possible. I will come on to the long-term funding in a moment, but I just want to address directly the question of short-term funding.

I query the Labour party’s motion because 80% of local authority funding was reliant on the central Government grant in 2010, and that is no longer the case. Looking only at the central Government grant is an inaccurate way of assessing the question. For instance, we introduced the social care precept directly to address some of these costs. It would be far better if this debate took place in the context of the available budget for social care, which is increasing by 8% in real terms over the four years from 2015-16 to 2019-20. The debate should be based on facts rather than partial facts, and that is how I will seek to proceed.

Quality is important, too, and 83% of adult social care settings are now rated good or outstanding by the CQC. The figure has risen from 79% in just the last year, and it is the highest since measurement started in 2014, but I want to see it rise further still.

The links between the social care system and the NHS are important, too. No one should stay in hospital longer than necessary.

[Dr Dan Poulter (Central Suffolk and North Ipswich) (Con)]

My right hon. Friend is right to highlight the link between healthcare and social care. If we are to care properly for people with the long-term conditions he has outlined, we need to have a more joined up and integrated system. It is hard to deliver that when we have a taxpayer-funded NHS and a social care system in which many people now have to pay for their own care. In looking for a cross-party solution, which he is open to, will he consider that we may need to look at a taxpayer-funded solution for funding social care so that we can deliver the transformative integrated care we want for older people?

[Matt Hancock]

Part of the social care system is, of course, tax payer-funded, but I also value the contributions that people make to social care. They are an important part of keeping the system strong. We dismiss those contributions at our peril, but I agree with my hon. Friend that we need to make sure we get more funding and better integration between the healthcare and social care systems. We can do that with different funding sources, as long as we have better organisation on the ground.

We must make sure we have the appropriate amount of care available so that people can leave hospital at the right time; people should not have to stay in hospital longer than necessary, as it reduces their dignity and quality of life and leads to poorer health outcomes, as well as putting unnecessary pressure on the NHS.

Since February 2017, more than 1,900 beds have been freed up in hospitals by reducing NHS and social care delays, yet we know that the winter months bring increasing pressure on adult social care services, which can have a knock-on impact on hospitals. On top of the rising social care budget, we are providing an additional £240 million for adult social care capacity this winter, which will help councils to get patients home quicker and free up hospital beds for more urgent and acute cases.

Today I have published the allocation for every local authority in England, and the Barnett formula will apply to allocations in Scotland, Wales and Northern Ireland. Individual allocations include, for example, £1.3 million in Salford and £1.5 million in Leicester.

Hepatitis C

Dan Poulter Excerpts

Tuesday 12th June 2018 Westminster Hall

[Sir David Amess]

The hon. Gentleman makes an excellent point. The hon. Member for Kingston upon Hull North (Diana Johnson) has done a fantastic job in bringing this issue to the attention of the whole House, but we must not take our eye off the ball. The hon. Gentleman is certainly right to remind me how important that issue is.

This country unfortunately lags behind Australia, Brazil, Georgia, Egypt, Germany, Iceland, Japan, the Netherlands and Qatar, which are all predicted to eliminate the virus within the proposed timeframe. I have said to my hon. Friend the Minister that we cannot really compare those countries with the UK, but it would be good if we could perhaps make even more progress on eliminating hepatitis C in this country. In the words of Polaris Observatory, the UK is “working towards elimination” of hepatitis C.

The APPG’s report highlighted awareness. First of all, it noted that awareness of hepatitis C has gradually improved in recent years, which we celebrate. However, awareness is still relatively low, and the stigma of having the virus remains a hurdle to people actually getting tested, diagnosed and treated in the first place. The report also found that there is low awareness of transmission risks among at-risk groups, with many people underestimating the seriousness of the condition and the urgency of accessing treatment. Even so, there are still misgivings among those with greater knowledge of the condition. Within that group, there is still a lack of awareness of new treatments that are available, and many still have worries regarding the side effects of former treatments.

The same is true of the stigma attached to the virus. Although it has decreased over time, the report found that progress still needs to be made in this area, as that stigma often acts as a barrier to people presenting themselves for testing or seeking treatment. The APPG therefore recommended initiating local and national publicity campaigns in an attempt to increase awareness. That is why I mentioned celebrities. Although I am not big on celebrities, I suppose that people do not listen so easily to us politicians—they tend to switch off. However, a so-called celebrity who is prepared to speak out publicly attracts more attention.

The report suggests two ways to increase awareness. One is among primary care professionals, through targeted testing initiatives in primary care, together with additional resources—it is always about securing more money—and support for primary care workers. The second is to raise awareness among at-risk groups through peer-to-peer messaging programmes. During my visit to HMP Wandsworth, I witnessed a peer-led group operated within the prison by inmates. It was wonderful what they had achieved.

However, it should be said that raising awareness of hepatitis C is in fact a short-term goal. Our long-term goal of eradicating the infection should see a switch to the offensive—to preventing the disease in the first place. That is what we are really aiming for.

[Dr Dan Poulter (Central Suffolk and North Ipswich) (Con)]

I congratulate my hon. Friend on securing the debate and more generally on all his work on this issue and on promoting effective liver health during the many years he has been an MP.

On prevention, given that intravenous drug use is one of the primary causes of the transmission of hepatitis C, does he agree that at the moment a lot of drugs policy is seen far too much through the prism of the criminal justice system? We need to bring that much more into the health domain. Effective working with prisons and with the Ministry of Justice is vital if we are to get on top of this issue, reduce infection rates and provide proper treatment for people who are infected.

[Sir David Amess]

My hon. Friend was a Health Minister and has real expertise in this area. I shall use the expression “joined-up government”. He is absolutely right that we need Departments to work together. That is why it was so good that we visited the prison.

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[Sir David Amess]

I am concerned by what the hon. Lady says. No doubt the Minister will eventually be passed a note from his officials and will advise us on the situation. That does not seem right if it is what is happening, and I hope that the Minister will correct me if that information is wrong. It is also vital to re-engage those who have been diagnosed and have slipped through the net to the point where they are no longer in touch with those services.

The APPG thinks that the way to combat these issues is to change how we test for the virus. We recommend routine testing in substance misuse services, sexual health clinics and prisons. We also advocate increasing testing in primary care and in settings such as hostels, day centres and police custody. I know that that will not be cheap, but if it could be done it would be wonderful. Another solution is to test for hepatitis C on occasions when people are already having blood tests, which seems like common sense to me. For example, should we not consider testing people for hepatitis C while they are being tested for HIV, or when taking blood in accident and emergency centres?

Diagnosis is one thing, but accessing care is another. It is therefore essential that people who are diagnosed are referred for treatment as soon as possible, without delay. There should be a direct link between diagnosis and care. The time between diagnosis and the commencement of treatment should be minimised, to prevent patients from dropping out of the care pathway altogether. One way to achieve that would be to make treatment available immediately following diagnosis. That may be ambitious, but it is, ideally, what our APPG wants. Another way would be to streamline the referrals process. As it stands, some secondary care services will only accept referrals for treatments from general practitioners. Allowing referrals from any service at which someone might be tested and diagnosed, as the APPG recommends, would go some way to solving the problem.

[Dr Poulter]

I agree entirely with my hon. Friend. One challenge that we face is the fragmentation of the commissioning of substance misuse services and sexual health services. Those are commissioned by local authorities under the Health and Social Care Act 2012, which I think we have to reflect on as a mistake in this context, as opposed to many secondary care services, which are commissioned by the NHS through clinical commissioning groups. Until we sort out that fundamental issue of commissioning, we will not be able to put in place the improvements that he suggests.

[Sir David Amess]

Oh dear! I say to my hon. Friend—I and, indeed, you, Mr Streeter, were in this place when we were dealing with all these issues—that the fragmentation is very worrying. My hon. Friend is right to point out that more work needs to be done on the issue.

--- Later in debate ---

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

It is a pleasure to serve under your chairmanship, Mr Streeter. Hepatitis C was identified about 25 years ago. When I was a young doctor, it was simply known as non-A, non-B hepatitis, because no one had any idea what it was. As the hon. Member for Southend West (Sir David Amess) said, we are talking about something that many people simply do not know they have. That is a key, underlying problem. Patients may only be aware that they have hepatitis C when they start to have liver symptoms, which is the start of cirrhosis or malignancy.

With any condition, we first want to prevent it. As was mentioned, at needle exchanges we already have blood screening to ensure that it is not coming from transfusion. We have to remember those in this country who previously suffered from contaminated blood that was iatrogenic—caused by doctors and the health service.

I agree with the hon. Member for Central Suffolk and North Ipswich (Dr Poulter) that we need a more medical approach to the issue of drugs. If we drive problems underground, there is no possibility of detecting and treating people, to achieve the elimination that the World Health Organisation is aspiring to.

In Scotland we are recognised as world leaders, in the sense that we had a strategy in 2005, 2008, 2011 and then our elimination strategy, which was introduced in 2015. The 2011 strategy fed into what became the World Health Organisation strategy, as one of our senior leaders was seconded to it. The big change is sofosbuvir and ledipasvir—the new antivirals that are well tolerated and able to clear the viral load in 90% of all patients. Of course we would prefer a vaccine, as the hon. Member for Strangford (Jim Shannon) mentioned; that is how we eliminated smallpox and how we are trying to eliminate polio. However, the problem with hepatitis C is that, as he said, there are six genotypes, but 50 subtypes, and it mutates regularly. It is one of those viruses with a coating that is very hard to get a handle on with the immune system and therefore to develop a vaccine for, so we need to use the drugs until a vaccine is available.

The Scottish Medicines Consortium passed sofosbuvir in 2014 and NICE passed it in 2015. Unfortunately, NHS England took the approach of trying to slow things down because the drugs are very expensive. However, dealing with liver failure and having to consider liver transplantation is even more expensive. A cap of 10,000 patients with cirrhosis and the most severe conditions from hepatitis C was set.

In Scotland in 2015, we took the opposite approach—a public health approach—to try to reduce the virus in the community and prevent it from occurring.

[Dr Poulter]

The hon. Lady is making very good points. I am sure she will correct me if I am wrong, but the other point to make is that in Scotland there has been a much more joined-up approach in tackling heroin addiction. Scotland is much further forward than England in addressing such issues, in having a co-ordinated strategy and in recognising how addiction leads to prisons and the criminal justice system. Indeed, there is not the fragmented commissioning of services that we see in this country. Does she agree with me that that is something that England can learn from in addressing the lack of joined-up working and commissioning?

[Dr Whitford]

I thank the hon. Gentleman for his comments. As NHS Scotland is still a single public body, we do not have the issue around commissioning. We are also trying to take a much more health-based approach to addiction. As happens in England as well, we have multiple needle exchange programmes. This place has held us back from trying to introduce safe injection in Glasgow, which has one of our highest drug-addicted populations and highest incidence of drug-related deaths. However, that initiative comes under the Home Office and we have not been granted permission to try to take it forward. Always taking a criminal justice approach gets in the way of achieving the medical outcomes that we want.

It is really important to recognise the breakthrough of the drugs. With an eight or 12-week course, expensive as it is, more than 90% of patients will achieve a sustained virological response. That means they remain with undetectable levels of virus 12 to 24 weeks after the end of their treatment. The problem with rationing treatment to those who are actually ill is that it is the people who are not ill with hepatitis who spread it to other people, because they are out and active. If they are drug users, they are still using drugs. Someone who is so ill that they are confined to bed is not spreading it. That is why we took a public health approach to eliminating hepatitis C over the coming years. We certainly aim to achieve that before the World Health Organisation target date.

As the hon. Member for Southend West said, one of the key issues is people not knowing that they have the virus, so, in Scotland, part of our approach has been to create opt-out screening at various points of blood being taken. That will be from general practice in areas of high prevalence. It already includes bloods taken in accident and emergency. It includes screening at other times such as when we screen for HIV. Obviously, we screen for HIV when a woman has her booking appointment at the time of her pregnancy. We need to use all the opportunities that we can. Of course a patient always has a right to opt out, but when we make something the norm it becomes easier for people to agree.

The prison population obviously has a big problem with drugs, including IV drugs—either in the present or the past, before the prisoners were incarcerated. It is important that we get the tests taken up by such populations.

We also offer testing in more social settings, where there have been education events around hepatitis and HIV and where peer-to-peer work has been done. It is important that we raise awareness and try to reduce the stigma. There is a problem with always talking about HIV drug users, as opposed to recognising that someone might have been contaminated by blood in this country, while undergoing maternity care or surgery overseas, or, as was mentioned, in a tattoo parlour: it means that people do not care. We end up with, “Well, it’s their own fault”, which maintains the risk to everyone else and hampers elimination. As well as raising awareness, we absolutely have to reduce the stigma.

It is important to take a public health approach, as we have done in Scotland. I commend that to NHS England, which should remove the cap and do as we are doing: try to set a minimum target for new people to be found and treated as soon as possible. We have seen the new cases reduce from 1,500 in 2007 to 700 in 2013, but it is the chronic cases that have been out there for years that we have to find because they still carry the virus and can spread it to other people.

Of course, NHS England should try to get the price down. There is no right for drug companies to profiteer as opposed to having a fair return, but the issue must be taken in the round. We must recognise that eliminating the virus by using drug treatments while we wait for a vaccine will overall be an huge benefit to society.

--- Later in debate ---

[The Parliamentary Under-Secretary of State for Health and Social Care (Steve Brine)]

It is genuinely a pleasure to serve under your chairmanship, Mr Streeter, and to be back in Westminster Hall on such a quiet day in Westminster. The hon. Member for Ealing, Southall (Mr Sharma) is sadly not in his place today, but I thank my hon. Friend the Member for Southend West (Sir David Amess) for securing and leading this debate. Although he said that he was not the best person to introduce the debate, he could have fooled us because he did it very well.

Hepatitis C is a significant health issue in our country, and for too long it has been overshadowed by other public health concerns that, despite the superstars involved, have had higher public profiles. I pay tribute to the Hepatitis C Trust and the wonderful Charles Gore, whom I have got to know in this job. He is a colossus in this area, and has become a friend. I also thank the Hepatitis C Coalition—this issue has been central to both those organisations.

My hon. Friend mentioned lots of local services for Southend residents, and a lot is going on in his constituency. Few MPs champion their constituency more than he does, so for his press release I will mention that screening and onward referral services are provided by the Southend Treatment and Recovery Service, known as STARS. For primary care, GP practices refer people to the specialist treatment services in my hon. Friend’s much-loved Southend Hospital. Local drug and alcohol treatment services in Southend hold outreach screening sessions for hepatitis, and all positive cases are referred for onward treatment. Big local successes that I noted in my papers included last year’s hepatitis C roadshow, which took place in my hon. Friend’s area, and there is the hepatitis C operational delivery network educational event 2018—he can see me after class for more details if he would like.

It is always good to see the hon. Member for Strangford (Jim Shannon) in his place, speaking so knowledgably and passionately about this issue, as well as the hon. Member for Central Ayrshire (Dr Whitford), and my hon. Friend the Member for Central Suffolk and North Ipswich (Dr Poulter).

The World Health Organisation has set ambitious targets to reduce the burden of chronic hepatitis C over the coming years, with a pledge to eliminate it as a major public health threat by 2030. The UK Government are committed to meeting and beating that target, as has rightly been said.

A few years ago, hepatitis C-related mortality was predicted to increase in our country, but through the measures that we have in place and the hard work and dedication of so many unsung heroes in the field, 9,440 treatments were delivered nationally against a target of 10,000 in 2016-17; the number of deaths fell for the first time in more than a decade, and that has been sustained for another year; and between 2014 and 2016, there was a 3% fall in deaths from hepatitis C-related end-stage liver disease. That is good news.

However, hepatitis C continues to make a significant contribution to current rates of end-stage liver disease. I welcomed the recommendations to tackle that in the report, “Eliminating Hepatitis C in England”, which was published in March by the all-party parliamentary group on liver health, of which my hon. Friend the Member for Southend West is co-chair. I often produce a recommendation-by-recommendation response to Select Committee reports in my area, but when I checked with my officials during the debate, I found that I did not do it for that report—I was not asked to by the group—but I offer to do so. In fact, I will go further than that—I will go crazy and do it. The group will get that from me as a written response to its report.

This is a timely debate, because NHS England recently launched its procurement exercise for the new generation of hepatitis C antivirals. If that exercise delivers successfully, the ambition is to eliminate hepatitis C as a public health threat earlier than the WHO goal of 2030, and to get to 2025.

[Dr Poulter]

Given the experience that we had with NHS England on HIV PrEP medication and its argument that that was a public health responsibility, which I believe was wrong and which was legally found wanting, will the Minister ensure that he holds its feet to the fire on hepatitis C so it recognises that although it is a public health issue, it has a responsibility for the effective procurement of antivirals and for making them available to all people with hepatitis C?

[Steve Brine]

Point taken; feet will be held to said fire. I do not think that NHS England is found wanting in this area, and I will go on to say why, but I take my hon. Friend’s point and will follow it through, because I want this to work.

The new industry deal may allow for longer contract terms that cover a number of years, but whether a long-term deal can be reached and what its duration is will be contingent on the quality and value of the bids submitted by industry. I expect the outcome of that in the autumn.

On local delivery networks, NHS England has established 22 operational delivery networks across our country to ensure national access to the antiviral therapy. I will touch on the issue of the cap in a minute. Those clinically led operational networks are given a share of the national annual treatment run rates based on estimated local need.

That local operational delivery network model ensures better equity of access. Many patients with chronic hepatitis C infections come from marginalised groups that do not engage well with healthcare, as has already been said. Through the development of networks, it has been possible to deliver outreach and engagement with patients outside traditional healthcare settings, such as offering testing through drug and alcohol services and community pharmacies.

As hon. Members know, I have a great soft spot for community pharmacies, and I think that they can and do play an important role in this space. In April, I hopped along to Portmans Pharmacy, which is just up the road in Pimlico, to see the pharmacy testing pilot of the London joint working group on substance use and hepatitis C that is going on there. I saw the testing and the referral to treatment that takes place in pharmacies that offer needle and syringe programmes across six boroughs in London.

Portmans Pharmacy has provided a needle and syringe programme and the supervised consumption of methadone for a number of years. Those points of contact with people who inject, or previously injected—a key distinction—drugs provide an ideal opportunity for us to make every contact count and to test for hepatitis C, as we think that about half of people who inject drugs in London have the virus.

The approach of Portmans Pharmacy and the London joint working group is innovative. It aims to provide quick and easy access to testing and a clear pathway into assessment and treatment in specialist care, which is obviously critical. I pay great tribute to the work that the group has done. It has rightly received a lot of coverage and a lot of plaudits. I am anxious and impatient—as my officials know, I am impatient about everything—to see the peer-reviewed results of that work and where we can scale it out more.

The hon. Member for Central Ayrshire mentioned treatment in respect of the cap. It is different north of the border, but NHS England offers treatment as per the NICE recommendations. The drugs that she mentioned are expensive, which limits the number of people who can be treated each year, but treatment has been prioritised for those most severely affected. The NHS then provides treatment to others who are less severely affected. So far, 25,000 people in England have been treated with the new drugs and a further 13,000 will be treated this year. The NHS procurement exercise should allow for even larger numbers to be treated each year. Of course, nothing is perfect in life. Resources in a publicly funded health system are finite, which is why we have to target them at the most challenged group. That is one of the reasons why making every contact count through primary care and pre-primary care, as I call community pharmacies, is so important.

[Steve Brine]

Of course, the hon. Lady states a fact not an opinion, and I accept that, which is why I speak of the importance of primary care and of making every contact count. The people who Portmans Pharmacy interacts with are not all sick. People who have a hepatitis C infection or a drug-use issue have other issues—they get flu too—so they interact with that pharmacy, and the pharmacy makes every contact count by grabbing people earlier. That is one reason why I am so passionate about the way that that underused network can help us to reach the ambitious targets that we have set.

Everyone has rightly talked about prevention—in many ways, I am the Minister with responsibility for prevention and it is the thing that I am most passionate about in our health service. As well as testing and treating those already infected, an essential part of tackling hepatitis C must be the prevention of infection in the first place, or the prevention of reinfection of those successfully treated, which would not be a smart use of public resources.

NHS England and Public Health England, which I have direct ministerial responsibility for, are actively engaged in programmes at a local level to prevent the spread of infection. As people who inject drugs or share needles are at the greatest risk of acquiring hepatitis C, prevention services, particularly those provided by drug treatment centres, are key components of hepatitis C control strategies. Clearly, the key to breaking the cycle of hepatitis C is to prevent infection happening in the first place.

[Dr Poulter]

The fundamental issue is that there is no greater evidence of fragmentation—I speak from my own clinical experience—and failure of joined-up working than the fact that local authorities commission substance misuse services but that the NHS commissions mental health services for the same patients and secondary care services for hepatitis C patients. People are falling through the gaps. Many people who have hepatitis C do not present to GPs, and are not even routinely on their lists, so the issue has to be looked at in a much more effective way if we are to make a difference.

[Steve Brine]

I hear my hon. Friend’s experience of the frontline and I would not disagree that in some areas there is unhelpful fragmentation. If I remember rightly back to those happy early days of the election of my hon. Friend and I to this place, we sat on the Health and Social Care Bill Committee. That piece of legislation, controversial as it was, enacted the decision to pass that responsibility to local authorities and, of course, all local authorities are now, in effect, public health bodies. All of them—well, top-tier authorities in England—have directors of public health.

Just because there are challenges and fragmentation, that is not a reason to redraw the system. I do not think there is any desire within the system for a top-down or bottom-up reorganisation—I suspect that, as a doctor, my hon. Friend would agree with that—but there is a challenge to the system to come up with a much better whole-system approach, to make sure that people do not fall between those cracks.

My hon. Friend and I could debate at length—I am sure we will—whether those cracks can ever be filled, and whether there will ever be Polyfilla that is big enough or strong enough to fill those holes, but I do not think that it is a reason to break open the system.

[Dr Poulter]

rose—

[Steve Brine]

I give way to my hon. Friend for the last time.

[Dr Poulter]

This fragmentation of commissioning is a really important point and it comes up in so many debates in Westminster Hall and, indeed, in the main Chamber. I urge my hon. Friend and indeed the rest of the health team—we have got to put right the things that we got wrong. If we want to get this issue right, and get it right for people with hepatitis C, and for people with mental health conditions who are not getting access to services because of this fragmentation, then we have to revisit it.

I urge my hon. Friend to go and spend some time out on the frontline with some professionals and to get them to talk to him candidly—not on a ministerial visit. He should get them to talk to him candidly about these problems, because we have to recognise that this situation needs to change for the benefit of the people we care about, who are the patients.

[Steve Brine]

I will not prolong this discussion, Mr Streeter, but I take my hon. Friend’s point and I think it is a subject that will receive further airing, to put it mildly.

ADHD Diagnosis and Treatment

Dan Poulter Excerpts

Tuesday 15th May 2018 Westminster Hall

[Jo Platt]

I completely agree. ADHD in the criminal justice system is an area that evidently needs a lot more investigation. The simple fact that an estimated 24% of the prison population are thought to have ADHD is a cause for concern.

[Dr Dan Poulter (Central Suffolk and North Ipswich) (Con)]

I congratulate the hon. Lady on securing the debate, and I draw attention to my declarations in the Register of Members’ Financial Interests. To enable early diagnosis, or any diagnosis at all, having the workforce in place is key. Recruitment of specialist child and adolescent mental health services doctors is a real problem. Unless we get that right, we will not deliver the service that patients and their families deserve.

[Jo Platt]

I thank the hon. Gentleman for that intervention. I completely agree that we need to highlight the workforce, but before we do that we need the data to see how many people we need in all workforces. Again, I will come to that point later.

--- Later in debate ---

[The Parliamentary Under-Secretary of State for Health and Social Care (Jackie Doyle-Price)]

I congratulate the hon. Member for Leigh (Jo Platt) not just on the passionate and articulate way in which she has introduced this important subject, but also on setting up the all-party parliamentary group. I am delighted to accept her invitation to come to a meeting and to hear some of the stories. I would also, through her, extend my congratulations to Michelle Beckett for her work in raising awareness.

The hon. Lady has highlighted that this group of people face quite intense, if unconscious, discrimination, because the way that our education system is set up does not really address their needs. That is something we should all wish to tackle. There are similarities with the way that autism and conditions such as dyslexia were treated in the past. If the abilities to learn are not there, people can fall out of the system. The truth is that they have a very different skill set and we should all be endeavouring to draw that out and, at the very least, not make them feel marginalised or discriminated against. As we have heard from other hon. Members, it is that sort of discrimination that leads them to fall out of the mainstream and perhaps fall into the criminal justice system, which is something that could easily be avoided if we were all more sensitive to it.

The hon. Lady mentioned data. I will take that away and look at it. It is fair to say that it is only very recently that the NHS has started to collect data regarding autism, for exactly the reasons highlighted today—the postcode lottery in terms of how different areas treat the condition. Quite often, it depends on having somebody in the area who gives a damn to give some leadership on the issue. Clearly, that is not good enough, as it will fail far too many people. I will go away and look at that. We have just introduced a new dataset for autism and I do not see any reason why we cannot extrapolate that methodology to look at ADHD. There is no doubt that we will continue our dialogue on these issues.

[Dr Poulter]

The Minister is absolutely right to highlight the issue of data, or the lack of it. In the interests of parity of esteem, is it also worth looking at introducing access targets in mental health for access to child and adolescent mental health services, which do a lot of the assessment of people with ADHD? Would that help drive better data collection in the NHS? Measuring against a target forces local healthcare providers to collect the data that is necessary to drive improvements.

[Jackie Doyle-Price]

I am just about to come on to issues about waiting times. The methodology that my hon. Friend suggests is absolutely right. Although it is Mental Health Awareness Week and we are looking at the issue through that prism, this is not just about mental health; it is about a learning disorder, and goes beyond that. Compartmentalising people who fall out of the mainstream as those with mental health issues is equally discriminatory, but we do have to ensure that we have the right care pathways for them to meet their needs.

[Dr Poulter]

I did not intend to come across as discriminatory in the point that I made; it is CAMHS professionals—mental health professionals—who tend to do the assessments for ADHD in children. What is the Minister going to do about the recruitment crisis in CAMHS? Without those CAMHS professionals, we shall not be able to provide the diagnosis and delivery of care.

[Jackie Doyle-Price]

My hon. Friend will be aware that we have addressed those issues in the Green Paper. We are investing in a whole new workforce in support of CAMHS, which will have a direct relationship with schools, where it will be possible for a lot of the wraparound help to take place.

I would like to make some progress on the specifics of ADHD and move on from CAMHS. The hon. Member for Leigh highlighted the massive variation in services across the country. I fully acknowledge that there are long delays for some to see a specialist and secure a diagnosis. That will clearly have a negative impact on those living with ADHD and their families, who can also find the experience confusing.

We are determined to see improvements in the patient journey. There are NICE guidelines. The earlier the diagnosis the better, and the better the chance of getting the right support and better outcomes for the individual. The NICE guidelines were published in 2016 and set out the process for managing ADHD for people aged three years and above. The guidelines aim to improve the diagnosis of ADHD, as well as the quality of care and support for people with an ADHD diagnosis.

An updated guideline was published in March this year, which particularly addresses under-diagnosis and misdiagnosis of ADHD in girls. People think it is just about behaviour, but in girls it does not play out in exactly that way; there is a lot to be done in education on exactly what this condition is. As the hon. Lady said, people think it is about bad parenting or bad behaviour when it is much more complex. The guidelines advise practitioners to be alert in such circumstances to the possibility of ADHD. We will be failing girls if we do not raise awareness of how that might be playing out.

The guidelines also recommend that people with ADHD would benefit from improved organisation of care and better integration of child health services, CAMHS and adult mental health services. Although NICE clinical guidelines are not mandatory, we expect health and care professionals and commissioners to take them into account fully as they design and put in place services to meet the needs of their local populations. NICE has published a range of tools to help local areas put the guidance into practice, but that is clearly not happening everywhere. I always find that sunlight is the best disinfectant, so the more we can do to ensure transparency, the better. That is why data is so important, as the hon. Member for Leigh said.

The NICE guidelines do not at this time recommend a waiting time for seeing a specialist for diagnosis, but they do recommend that parents of children whose behaviour is suggestive of ADHD should be offered a referral to group-based ADHD-focused support without waiting for a formal diagnosis. That will clearly be helpful, but we should also look at the waiting times.

An issue that I am particularly concerned about—I look forward to engaging with the APPG on this—is support for schools, which the hon. Lady mentioned. Getting the right support package for children with ADHD can be challenging for some institutions. I am concerned that anecdotal evidence suggests that people are being excluded disproportionately, so we really need to tackle that discrimination. Perhaps I can ask the APPG what we can do together to give schools extra support and better advice about how to support children with this condition, rather than simply marginalise them.

The Children and Families Act 2014 and the special needs code of practice set out ways in which care services should join up, and we need to hold them to account. We expect CCGs and local authorities to work together to support children with special educational needs or disabilities, including ADHD. That includes co-ordinating assessments of individual needs and, for those with the greatest needs, providing an individual education, health and care plan. I am interested in hearing evidence from the APPG about how many children are not receiving such plans.

I am not going to stand here and pretend that everything is perfect, because I know perfectly well that it is not, but we have the opportunity to highlight good practice, help local authorities and CCGs to learn from it, and highlight when people are being failed.

Mental Health Services (Norfolk and Suffolk)

Dan Poulter Excerpts

Wednesday 2nd May 2018 Commons Chamber

[Dr Dan Poulter (Central Suffolk and North Ipswich) (Con)]

I thank you, Madam Deputy Speaker, and Mr Speaker for granting this debate on mental health services in Norfolk and Suffolk and the challenges they face.

Quite rightly, the Government have talked a lot over the last few years about parity of esteem between mental and physical health and about the need to invest more in mental health services. Indeed, there has been limited extra investment in Norfolk and Suffolk. None the less, the NHS trust has faced challenges that are affecting the quality of patient care. Tonight is a good opportunity to bring before the House some of those issues and, hopefully, to offer some solutions and appeal to the Government to do more to help the trust in very difficult times, because ultimately it is the patients who suffer when trusts are in difficult circumstances.

First, I would like to pay tribute to Gary Page, who is the chair of the Norfolk and Suffolk mental health trust. Despite very challenging circumstances, difficult Care Quality Commission reports and the financial pressures that have faced services in Norfolk and Suffolk for many years, he has worked hard to make sure that there has been continuity. It is thanks to his leadership that the trust is now able to move forward and address some of the challenges that it faces with the quality of care.

I want to talk briefly about some of the issues involved, focusing mainly on ward closures and the points raised in the CQC report. I want to outline to the House some of the fundamental issues with staff shortages, which are probably the worst in almost any mental health trust in the country. I want to talk a little further about the finances of the trust, and I also want to talk about some of the difficulties there have been in how the trust works with addiction services and how that is counterproductive to the effective care and treatment of patients.

Although my medical work is not currently in the east of England, I want to draw attention to my declaration in the Register of Members’ Financial Interests. I am a practising NHS doctor working in mental health services, which of course gives me some insight into the challenges faced by the trust, although I do not think that interest is particularly applicable in this case, because my medical work is not done in the region.

The quality of care challenges facing the trust are quite extensive. As the Minister will be aware, the trust was put into special measures in October 2017. There are significant pressures on beds within local services, resulting in higher numbers of out-of-area placements for patients. Many patients are now having to be transported out of area to be treated because of the closure of beds, which is not good medical practice. It is not good for patients either, because they will be a long way away from their support networks, and it interferes with the effective post-hospital care and rehabilitation that is so important in co-ordinating with community services.

The challenges appear to centre on patient flow into beds and delays to discharge. We know that there is a historical lack of community mental health services in Norfolk and Suffolk, and investment has not been available to increase them at the necessary speed and rate. There are challenges with housing providers in the area not necessarily working closely enough with the trust, and there are also the pressures on social services that we know too well exist across the country. Those pressures are very relevant in Norfolk and Suffolk, where we have a lot of older patients with dementia who are struggling to be discharged effectively into the community because of delays in receiving adequate social services. A lot of the blame for that has been attributed to the mental health trust, but many factors are beyond its control.

The trust also faces significant challenges with the quality of its buildings infrastructure. Many of its buildings are old and not fit for purpose. The capital budget has not been available to improve the buildings, although there has been some new building work. I will come on to that in a moment.

[Sandy Martin (Ipswich) (Lab)]

My meetings over the past three weeks with the new chief executive and others have given me cause to hope that the structural problems are now being addressed. A new co-produced community services partnership, commissioned by the clinical commissioning groups and involving Norfolk and Suffolk NHS Foundation Trust, Ipswich and West Suffolk hospitals, the county council and the GP federation, is embarking on a level of integration that has never been tried before in the United Kingdom, working with district councils, schools and the voluntary sector to make mental health everyone’s business. Does the hon. Gentleman agree that the Government have a real interest in seeing whether that model can succeed? Will he support me in calling on the Minister to provide sufficient pilot funding for the project, so that Norfolk and Suffolk NHS Foundation Trust can recruit the staff it needs to make the new model capable of success?

[Dr Poulter]

I thank my constituency neighbour for that intervention. I entirely agree with everything he says, although I am not sure it is quite so pioneering—I think the hospitals in London would probably disagree with that. There is a lot of good work going on in London built around exactly that sort of model of more integrated care.

One of the challenges faced by the trust in the past, and which mental health trusts in general face, is the failure of many partner organisations to properly engage on issues such as the provision of adequate social care for patients with chronic and long-term mental illness and dementia. There is also the failure of housing providers to be involved and of the police to be properly involved. There is a big overlap between some people with mental ill health and presentation to the police, when they would be better looked after by the NHS.

This project is the right way forward, with more integration of services and better integration between mental and physical health. Many patients with chronic mental health needs have physical health problems. They are sometimes a side-effect of the drugs, but are often a result of a chaotic lifestyle. Better joined-up working with the local NHS undoubtedly has to be a good thing. For that to be effective, however, as we have seen in some pilot projects in London, there needs to be the funding to deliver it. The mental health trust is not in the best financial shape—I will come on to that later—and support from the Government through funding for this innovative way of working, which I think is certainly a first in a rural area, would be very welcome. I hope the Minister may be able to provide some reassurance on that this evening.

[Peter Aldous (Waveney) (Con)]

I congratulate my hon. Friend and constituency neighbour on securing the debate. Before he goes on to talk about the money, which is very important, does he agree that it is very important that the trust promotes and endorses local, tailor-made initiatives such as the trauma-informed approach currently being promoted in Lowestoft by mental health champions Tod Sullivan and Paul Hammond?

[Dr Poulter]

Yes, that is absolutely the right way to provide integrated services and joined-up care, because we cannot necessarily have a one-size-fits-all approach across Suffolk or Norfolk. We need to look at the local healthcare need. That is partly about working not just with housing providers, social services providers, primary care and GPs, as I believe is happening in my hon. Friend’s constituency, but with the voluntary sector, other third sector providers and local charities, many of which have knowledge of the needs of patients, families and carers. When we are providing joined-up, holistic mental healthcare, it is just as important to make sure that the approach is joined up and holistic in that regard, and I believe that the project in my hon. Friend’s constituency will have a very good chance of improving services for patients.

[Jim Shannon (Strangford) (DUP)]

Will the hon. Gentleman give way?

[Dr Poulter]

I will make a bit of progress first and give way in two or three minutes.

The challenge from a lack of bed capacity is acute; 36 beds have been closed in recent months, 28 of them temporarily to be reopened as soon as possible. One of the challenges, as my constituency neighbour, the hon. Member for Ipswich (Sandy Martin) said, comes from the lack of joined-up working and a failure of commissioners, to some extent, to work collaboratively with the trust to identify short-term solutions. None of us wants to see patients travelling outside Suffolk. The commissioners have not worked well with the trust, because beds are available. My neighbour, my hon. Friend the Member for Bury St Edmunds (Jo Churchill), who is unable to speak because of her Government role, has rightly highlighted that bed capacity is available at the Chimneys in Bury St Edmunds—18 beds, including specialist eating disorder beds, which are available and could be commissioned if the commissioners worked more collaboratively and supported the leadership of the trust more effectively. I hope that will come out of the collaborative and pioneering work on which the trust’s partners are now supporting it.

None the less, there are some positive things to point towards. Building work is going on to deliver some new wards, and it is hoped that Lark ward in Ipswich, the psychiatric intensive care unit, will be able to reopen later this year. There are hopes that more can be done for child and adolescent mental health services, with continuing expansion in the number of beds.

[Jim Shannon]

I congratulate the hon. Gentleman on securing the debate. I sought his permission to intervene beforehand and told him why I wanted to. With the prevalence of mental health issues 25% higher in Northern Ireland than in the rest of the United Kingdom, and with our NHS unable to meet the demand on the service, does he not agree that mental health reform must be UK-wide and undertaken urgently, before people who simply need a bit of help to cope become people who need in-patient care and a strong drug regime to survive? Do it now and it can stop problems later.

[Dr Poulter]

I agree entirely with my hon. Friend. He is always a strong advocate for the needs of his Strangford constituents. He is right to highlight that early intervention and early support can be very effective. That is partly because it often prevents some of the other unwanted effects of having a mental illness. When people have been untreated for a long period, they may well lose their job and struggle with their relationships. A number of the supportive and protective factors that can help to support someone through mild and moderate ill health, such as being in work or in a supportive relationship, can be lost. If we can do more to help people in the early stages, that is a good thing—quite apart from it potentially reducing the number of acute admissions later on.

I want to make the important point that the staff shortages at the trust are one of the major challenges that need to be addressed. It is frankly, and I do not use this word lightly—I do not think I have ever used it before, even though we often hear it used by politicians—a scandal that there is such a shortage of staff at Norfolk and Suffolk mental health trust. I hope the Minister can think of better ways to fund and support the trust. Without enough staff, it cannot expand services or deliver safe services. The trust has struggled with CQC inspections because there are not enough staff on the ground to deliver the care it wants to deliver. That is not entirely the fault of the trust, however, as it is constrained by its funding.

I will outline some of the issues that the trust faces. It has had difficulty recruiting band 5 registered mental health nurses—there are approximately 125 full-time vacancies; there are 35 full-time equivalent vacancies for psychiatrists, partly owing to a national shortage, but also owing to particular challenges in the east of England; almost one in five medical posts at the trust are vacant—that means that doctors who should be there treating patients are not because of staff shortages; and 16.02% of qualified nursing posts are vacant. That is not acceptable or sustainable. If we are to improve patient care and help the trust to turn around, the fundamental issue of recruitment has to be addressed. There are fewer than 15 psychiatrists per 100,000 people in the region, which is much lower than the national average. In fact, the east of England has the fewest psychiatrists per head of population in the country.

Doctor recruitment is not a good story either. Issues with the junior doctor contract might not have helped, but we are where we are. Recruitment for CT1 junior doctors in 2017 saw only 16 of 45 vacancies filled—that is 36%—so only one third of the number of doctors who should have started training at CT1 level are working in the trust. That is a big rota gap to fill and will of course affect patient care. In 2015-16, about one third of ST4 vacancies in child and adolescent psychiatry were filled. In general adult psychiatry, which is the bread and butter of psychiatry, only nine of 18 posts were filled in 2015. In 2017, only five of 22 posts were filled, which means that less than a quarter of posts for registrar trainees in general adult psychiatry are filled. The story goes on and is equally bad in older-age psychiatry—and we have a lot of older people with dementia to look after in the east of England.

Recruitment, then, is vital. We have to do more to recruit psychiatrists. The current strategies are not working, so I ask the Minister to look at what has been successful overseas—in Queensland, Australia, and other places—and to put financial incentives in place to support nurses and doctors to come and work in the east of England, because at the moment patients are paying the price for a lack of doctors on the ground. The trust is doing its best to recruit, but it needs extra financial support through Health Education England, and it needs to be given support and the go-ahead from the Department. We know from elsewhere in the world that financial incentives work in rural and coastal areas, as long as doctors and nurses are helped with a relocation package. The Department’s successful health visitor programme is a good example of how financial incentives can work. I hope she will look at that.

The pressures on the trust’s finances have been there for many years—since the merger of Norfolk and Suffolk mental health trusts—and we know that mental health has been underfunded nationally for decades. The trust needs £9.2 million to meet CQC recommendations for improvement. Some £4 million can be funded from the capital budget, but given that the CQC has criticised the building’s infrastructure, it seems ironic to raid the capital budget for buildings and infrastructure and put it into the revenue budget to deal with immediate quality of care issues.

Even with that £4 million, however, there is still a shortfall of £5.2 million, and that was the subject of a recent funding bid to NHS England. The bid will be resubmitted fairly soon, and I hope the Minister will encourage NHS England to look favourably on it. It is important that the trust is given the financial wherewithal to deal with the quality issues raised by the CQC, to reinvest in vital community services and to undertake the vital work on integration that my constituency neighbour, the hon. Member for Ipswich, mentioned in his intervention.

There is some positive news. The ligature reduction project is proceeding successfully, and some good work is being done in the rebuilding programme at Chatterton House. The Norfolk and Waveney perinatal mental health service was launched in September. I pioneered support for the expansion of perinatal mental health services when I was a Minister, and I am pleased to see that it is now happening on the ground. In February a specialist perinatal mental health service was launched in Suffolk, which is a very good development. However, severe challenges remain and need to be addressed.

Finally, let me say something about services for patients with addictions. I will be brutally honest: I think that we created a problem with effective addiction treatment through the Health and Social Care Act 2012. The commissioning of addiction services has been transferred to local authorities, although the bulk of mental health services and physical health care for patients with addictions is still run by the NHS.

In the east of England, the amount invested in drug misuse services has been reduced by about £6 million over the last four years. Drug misuse is a serious challenge in areas such as Lowestoft, Ipswich and Norwich, not just as a result of underfunding but because those services are not working in a joined-up way with mainstream physical and mental health services. That must be addressed as a matter of urgency, because patients are falling through the net and not receiving the holistic care that they need. Many end up in the criminal justice system as a result, and the police and, in some cases, communities are picking up the pieces because of the failure to provide joined-up care for those patients. The lack of substance misuse services as part of any NHS system affects the dynamics and practicalities of good care, such as the sharing of information. Barriers are created, and the good intentions of staff on the frontline are undermined. That has an adverse effect, and I am sure that we will continue to see a rise in the number of drug-related deaths as a consequence.

Let me ask the Minister some questions. What additional support can be offered to the trust to help it to deal with its historical and current financial challenges and transform its services in the wake of the CQC’s report? There is a shortfall in funding; the trust has submitted a funding bid, and I hope that the Minister will support it. What additional resources can be made available to improve the recruitment and retention of psychiatrists and nurses, and what can be done to attract junior doctors to the east of England? One in five doctors who should be at work are not there because of staff vacancies. What steps are being taken to stop the transfer of patients out of area for treatment? Finally, what can be done to ensure that there is proper integration of addiction services with mental health services in our region, to ensure that patients are given a better deal?

It is time for the rhetoric about mental health to join up with the reality, and for patient care to improve. It is time for Norfolk and Suffolk mental health trust to be given the support that it needs, so that it can do the best for its patients.

Cancer Targets

Dan Poulter Excerpts

Tuesday 1st May 2018 Westminster Hall

[Mr Baron]

I have a lot of sympathy for what the hon. Lady says, and that is why I think that cancer alliances have a decent role to play. They can take more of an overview and more responsibility for ensuring that best practice spreads and is learned from, but they can also take more of a role when it comes to clinical evidence in relation to treating cancer. My suggestion to the hon. Lady is this: if we get the NHS properly focused on improving its one-year figures and, therefore, its five-year figures, it will come closer to embracing the journey as a whole and coming up with initiatives, particularly at primary care level, that are designed to encourage earlier diagnosis. I fully accept that that is not the only answer—it is about supporting people and so on—but at the end of the day we are using blunt weapons to try to improve cancer survival rates, and the evidence clearly shows that we are not succeeding.

I will make some progress, but I will be happy to take more interventions later. In recent decades, the NHS has been beset by numerous process targets, as we have just discussed. Those have a role to play. It would be too revolutionary for me to stand here and say that we should discard them all and just bring in the one-year figures. I think that that would be too much for the NHS to grasp, but I do believe that process targets are too blunt a weapon. They offer information without context and, in my view, can hinder rather than help access to good treatment, especially when financial flows are linked to process targets, which has been the hallmark of our NHS since 1997. What is more, those targets, being very ambitious, have a tendency not to be met—a point made by the hon. Member for Strangford (Jim Shannon)—except in the very best of circumstances. They can easily become, as I have suggested, a political football between parties eager to score short-term points when in reality a longer-term approach is required. All sides are guilty of that.

Cancer has been no stranger to process targets. As I have mentioned, the House of Commons Library suggests that no fewer than nine process targets currently apply to cancer, most notably the two-week wait to see a specialist after a referral and the 62-day wait from urgent referral to first definitive treatment. Process targets, as I have suggested, can pose a particular problem when the NHS’s performance against them is used as a metric to control financial flows, which tends to skew medical priorities. Such targets are only part of the journey when trying to improve one-year survival rates, yet CCGs, although held accountable for outcome measures, in practice follow process targets, because they are the key to unlocking extra funds. That is one of the key issues that we need to explore further in the months and years ahead. I am talking about the fact that process targets account for only part of the journey when we need a longer-term view.

I also suggest that process targets are not the best means of helping when it comes to rarer and less survivable cancers, which for too long have been the poor cousins in the cancer community. Rarer and less survivable cancers often fall between the cracks of process targets. Data on those cancers is not used routinely in much of the NHS. That encourages the NHS to go for the low-hanging fruit of the major cancers. That has to change. Given that rarer cancers account for more than half of cancer cases, serious improvements in cancer survival will not be possible unless rarer and less survivable cancers are included. Outcome measures have the advantage of encouraging their inclusion when seeking to catch up with average international survival rates.

The all-party group’s most recent report, launched at the Britain Against Cancer conference in December, highlighted an example of how process targets can act against patients. In 2016, as I think all hon. Members in the Chamber will be aware, NHS England announced £200 million of transformation funding, intended to help the newly formed cancer alliances to achieve the standards set out in the five-year cancer strategy to 2020, and bids were invited. This should be straightforward. An extra £200 million is coming in and is being handed over by the Government to NHS England. The money should be going where it is most needed—to help cancer services at the front-line to deliver on the cancer strategy.

However, after the bidding process closed, a requirement for good performance against the 62-day target was introduced retrospectively. That was after the deadline—by some weeks, if not months. It resulted in multiple alliances whose performance was not deemed good enough not receiving their expected funding allocation. Oral and written evidence was taken by and submitted to the all-party group last autumn. I see members of the group in the Chamber. For those who arrived late, I point out that I have thanked the members for their help and stalwart support over the years. The oral and written evidence given to the group when we were conducting our inquiry suggested that the retrospective application of the 62-day condition was causing real problems at the frontline. We heard in effect a cry for help from those at the frontline of our cancer services. Our December report, as the Minister will be fully aware, called for a breaking of the link between the 62-day target and access to the transformation funds. Let us break that link and get the transformation funding down to the frontline, where it is needed to help to implement the cancer strategy.

It is an iniquitous situation, as the conditionality on process targets prior to funding release means that high-performing alliances receive even more money, while those that are struggling and could therefore most benefit from the extra investment do not receive the extra support. That is against the whole spirit of transformation funding.

[Dr Dan Poulter (Central Suffolk and North Ipswich) (Con)]

I congratulate my hon. Friend on securing the debate and thank him for all that he has done to raise these important issues consistently during his time in the House. I, too, must leave a little before the end of the debate, so please accept my apologies, Mr Streeter. With regard to funding, notwithstanding the fund that my hon. Friend has mentioned, NHS core funding often tends to be diverted to prop up the acute sector during winter crises; that happens year after year. We are now missing cancer targets, whatever we think of them—they have ceased to be meaningful to many trusts at local level. Does he therefore agree that, if we are to make a difference, we must ensure that more of the money from the core NHS budget goes to community services and cancer services?

[Mr Baron]

I broadly agree. Although a system as big as the NHS must always be able to respond to short-term emergencies, such as the winter crisis, longer-term thinking is needed to address key issues such as cancer survival. At the moment we have an absence of long-term thinking, let alone long-term funding, which is harming patients to the extent that we are not focusing on outcomes. In 2009 the then Department of Health’s own figures showed that 10,000 lives were needlessly lost because we were not meeting European averages for survival rates. I agree that we need longer-term thinking, and that is where outcome indicators, such as one-year and five-year cancer survival rates, would encourage not just long-term thinking, but long-term funding.

--- Later in debate ---

[Dr Poulter]

My hon. Friend makes a good point. When we talk about quality-adjusted life years—there are other measures of the cost-benefits and cost-efficiency of treatments—it seems extraordinary that a more holistic view is not taken, particularly looking at quality-of-life indicators in cancer treatment. I am sure that he will want to press the Minister on that.

[Mr Baron]

I am sure that the Minister has taken that on board and I look forward to his comments. It goes without saying that the earlier we diagnose, the more money we save, which could then be ploughed back into frontline cancer services. We need to try to quantify that, and we are nowhere close to doing that at the moment.

That is why, in conclusion, I come back to the point that we need to take a longer-term view on our plans for cancer care—longer-term funding and thinking. Process targets actually act against that, because the focus is on specific issues, which can skew priorities, particularly when they are associated with funding. In the end, that has proven not to be in the best interests of patients, given our failure to catch up with international averages. Outcome measures retain the focus on accountability, which quite rightly governs our health service. They provide the best of both worlds: they encourage long-term thinking and long-term funding, while at the same time we as politicians rightly have to hold the NHS accountable. We are talking about £115 billion to £120 billion of taxpayers’ money. We have to ensure that there is the element of accountability in the system, but that is where outcome indicators could be very helpful.

One cannot cover everything in a debate such as this. I am glad that the HPV issue will be given a proper airing in tomorrow’s debate. I think that the vaccine should be extended to boys. I also think that the big issue of prevention is important. Healthier lifestyles make for lower cancer risks, but this specific debate is about targets. It has been a helpful debate and I thank everyone for their interventions. I look forward to other contributions and to the Minister’s comments at the conclusion.

NHS Wholly Owned Subsidiary Companies

Dan Poulter Excerpts

Tuesday 6th March 2018 Westminster Hall

[Liz Twist]

I most certainly agree that the issue is a dangerous one that needs to be looked at, and it is a very worrying one because, whatever happens, the staff who have transferred are in a very difficult position.

In the longer term, the establishment of the wholly owned subsidiaries leaves services open to privatisation in the future, continuing the fragmentation of our NHS, which is not in the long-term interests of all who use the NHS. There is no evidence that the plans will improve efficiency or productivity in the NHS. They exploit a tax loophole and seek to exploit the future workforce.

[Dr Dan Poulter (Central Suffolk and North Ipswich) (Con)]

The hon. Lady and her colleagues are right to highlight the fact that the financial pressure on the NHS is the main driver for this situation. Does she agree that it is very difficult in some services to differentiate between administrators and back-office services, and frontline services? Sometimes, administrators and back-office workers are embedded in clinical teams, and this actually worsens fragmentation and makes it much more difficult to deliver high-quality patient care.

[Liz Twist]

The hon. Gentleman makes an excellent point. NHS staff, whatever their job, are all part of a team that delivers a service, and they all work together. For example, the catering and cleaning staff who looked after my mum’s hospital ward when she was in hospital recently were also a part of the NHS caring process. I think that is a really important point.

--- Later in debate ---

[Stephen Barclay]

Again, that is a complete misrepresentation. The trust itself has pointed to the benefits of the arrangement. Let me give a concrete example of how the arrangement is delivering to the trust savings in the interests of patients.

Under the previous delivery system, local pathology samples were sometimes lost and delayed—that is not in the interests of patients. The QEF brought in a revised system of procuring all sample containers and issuing those to GPs across the region before delivering samples to the hospital pathology laboratory hubs within four hours. The trust forecasts that that will deliver significant benefits—indeed, other trusts are interested in the services. By operating on a more commercial model, therefore, not only has the trust improved how it deals with samples and prevented those samples from being lost as in the past, but it has put in place a system that is better for patients and attractive to GPs in other trusts who now want to contract the services.

[Dr Poulter]

The Minister is slightly at odds about the point being made. The point is not how it is open to the trust to procure the best clinical services but how, later, through a company, staff might be re-employed on a lower salary. Clearly, trusts already have flexibility through “Agenda for Change” to start people on a higher pay point, but I wondered more generally whether my hon. Friend supports national pay bargaining and “Agenda for Change”.

[Stephen Barclay]

The Chancellor made his support for the “Agenda for Change” programme clear in the Budget. My hon. Friend is aware of the commitment that the Chancellor made to fund that outwith the spending review 2015 process. That is a matter of record and one my hon. Friend is well aware of. The point being made, however, is that the flexibilities are popular with staff within the trust. Again, that is not simply a matter of me saying that; it is reflected in the staff survey of those working at the trust.

NHS Negligence Cases

Dan Poulter Excerpts

Tuesday 30th January 2018 Westminster Hall

[Andrew Gwynne (Denton and Reddish) (Lab)]

I beg to move,

That this House has considered NHS negligence cases.

As always, Mr Rosindell, it is a pleasure to see you in the Chair. I know that it is highly unusual for a member of the shadow Cabinet to speak from the Back Benches, so I am grateful to the Opposition Whips and to Mr Speaker for allowing me to do so as a final opportunity to seek some form of closure for my constituent in this very serious matter. I am especially grateful to Mr Speaker for granting this debate.

Sadly, I have to publicly outline how my constituent, Mr Hawkins, has been let down by public authorities. The law and NHS rules have been abused to avoid giving him the justice that is rightfully his. His attempts to seek that justice, along with some semblance of honesty and humility, have already passed the decade mark, so I shall be grateful for the Minister’s reply after I set out the case.

Mr Hawkins was admitted to Tameside General Hospital on 28 June 2006 to undergo surgery to repair a ruptured left Achilles tendon. Rupturing an Achilles tendon can tear it partially or completely, making walking difficult and the ankle feel weak. The surgery was listed for theatre in the afternoon under the care of an orthopaedic consultant surgeon, Mr Ebizie, but then postponed to the evening. My constituent believes that the most simple and sensible solution would have been to postpone it until the next day, allowing him to remain under the care of the same surgeon. He believes that that did not happen, however, because it would have meant the hospital missing its five-day Government target for a patient to receive treatment or surgery after attending accident and emergency. Records indicate that the surgery was instead carried out by Dr Manikanti, assisted by Mr Kumar. Mr Hawkins states that the change of surgeon was made without his knowledge or consent. Subsequently, both clinicians have left the hospital and the country, and the names and titles of those who carried out the surgery have been disputed.

Mr Hawkins states that the surgeon made a critical clinical error. He believes that the surgeon misunderstood the positioning of the two diagonal sutures forming part of the modified Kessler suture. They were brought to the surface and closed, which permanently fixed the repaired Achilles tendon to the rear of his leg. On 7 July 2006, nine days after the surgery, the plaster cast was removed, revealing an open wound between the two sutures. Steri-strips were applied in an attempt to close the wound, but the duty consultant wrote in his records that the wound had healed very well after surgery. Mr Hawkins states that despite being aware of the error, the hospital failed to correct it by releasing the repaired tendon from the rear of his leg as soon as was medically possible. This allowed serious adhesion and tethering to form as the sutures disintegrated.

On 12 January 2007, Mr Hawkins was discharged from the care of Tameside Hospital. Throughout the previous months, the repaired Achilles tendon had been continually swollen because of the aggravation of the fixation. Mr Hawkins raised concerns, which were ignored. Weekly and monthly appointments at the hospital were required thereafter. Mr Hawkins believes that he was discharged by Tameside Hospital before he was clinically prepared and regardless of his condition. He feels that that was done to conform to Government targets.

Mr Hawkins immediately made a complaint through the hospital trust’s internal complaints procedures. He believes that on receipt of his letter of complaint, the trust should have called him in for an examination and a scan. It should have admitted that a serious problem had occurred and carried out a further operation to release the Achilles tendon from the rear of his leg. In Mr Hawkins’s mind, the matter would then have been resolved. However, the trust decided to take a different route: it instantly instructed Hempsons solicitors.

Although, obviously, Mr Hawkins is concerned about the clinical errors that have caused him lasting damage, he is rather more appalled by the actions of a variety of organisations afterwards. He believes that those actions were deliberately designed to cover up the fact that a clinical mistake had been made, caused primarily by the replacement of a consultant surgeon with a junior doctor.

In 2008, Mr Hawkins instructed a solicitor, who requested disclosure of all full medical records. The trust passed his request on to Hempsons. However, in the immediate period after his request he received only a very selective number of his own medical files from Hempsons. Mr Hawkins’s solicitor failed to ensure that all full medical evidence was disclosed within statutory time limits and failed to apply for a court controlled disclosure, while knowing that the records he had listed were missing. Mr Hawkins’s solicitor instructed a clinical litigation medical expert, who produced a case-closing report that failed the objectivity test and was therefore invalid. The trust and Hempsons initially failed to disclose relevant medical records, doing so only after continued and considerable pressure from Mr Hawkins.

[Dr Dan Poulter (Central Suffolk and North Ipswich) (Con)]

The hon. Gentleman is a strong advocate for his constituent and makes a compelling case about the difficulties that his constituent has faced. Does he agree that the case flags up a wider problem? He mentioned solicitors being involved at a very early stage in the process. The current system for dealing with medical negligence in hospitals pushes defensive medicine and defensive approaches from hospitals. That fundamentally needs to change, because it is not good for doctors and it is not good for patients. Does he think that no-fault compensation may be a good way forward?

[Andrew Gwynne]

The hon. Gentleman makes an important point. As Mr Hawkins himself acknowledges, if the hospital trust had taken his complaint down a different route by accepting that it had made a clinical error and deciding to put it right, I would not be standing in Westminster Hall today raising his case.

Mr Hawkins continued with his complaint. In 2013, the trust eventually conceded and his remaining medical records were fully disclosed. On analysis of the records, it was plain to see that there were omissions and that pre-action protocol time limits had been exceeded. In response, Hempsons sought the opinion of a medical litigation expert. A report was produced, but it was based on the selected medical records that I mentioned earlier, as well as on the falsified information. Mr Hawkins believes that that report would fail any objectivity test and is therefore invalid.

Mr Hawkins had involved the Information Commissioner’s Office on two occasions: in 2009 and in 2013. In both instances, it judged that the Data Protection Act 1998 had been breached by the trust’s failure to disclose relevant medical records on several occasions. After much time and effort from Mr Hawkins, on 11 December 2013 the new management team at the trust finally admitted to maladministration and awarded remuneration for it. In a move that Mr Hawkins believes was an attempt to close his complaint and prevent the case from going back to the Information Commissioner, or to the court for disclosure, the new management team disclosed that it would no longer discuss actions taken by the old management team. Mr Hawkins also believes that the Limitation Act 1980 was breached from 2008 and that rules 31 and 35 of the Civil Procedure Rules 1998 were breached in compiling medical reports, because the medical experts failed in their duty to the court to be objective.

The delays in disclosure of information meant that Mr Hawkins’s complaint to the Parliamentary and Health Service Ombudsman was ruled out of time. My constituent believes that that makes a mockery of the trust’s failure to disclose his medical records within statutory time limits, which he believes the ombudsman ignored while upholding the strict time criteria regarding his making a complaint to the ombudsman.

Mr Hawkins appealed the decision on several occasions when the evidence was retrieved through the Information Commissioner. However, he was unsuccessful in overturning their original view that a letter from the trust indicated that the complaint was closed in 2007, which he utterly refutes. Hempsons later apologised and admitted that that letter did not clearly state that the local complaints procedure was closed. However, the ombudsman still refused to investigate the complaint and, in doing so, Mr Hawkins feels that the ombudsman has assisted the trust to conceal the cause and effects of a clinical error.

In 2013, Mr Hawkins wrote to the NHS Litigation Authority, as the trust was not reporting clinical mistakes. Initially, the NHS Litigation Authority would not get involved and requested my involvement, as Mr Hawkins’s Member of Parliament, which I duly offered. Two replies were received that indicated that the NHS Litigation Authority was involved in the case, despite previous assertions and written evidence that it was not involved. Mr Hawkins was notified in writing that the trust, on receipt of his letter of complaint, had instructed Hempsons in January 2007, with the NHS Litigation Authority directly instructing Hempsons and the trust from November 2007 to February 2009.

Hempsons was aware of a breach of the Limitation Act 1980 and the Data Protection Act 1998 when it disclosed to Mr Hawkins his missing medical records in October 2009. This means that the trust and Hempsons had illegally avoided disclosing all full medical records within statutory time limits and successfully passed the three-year limit for litigation. Mr Hawkins believes that indicates that the NHS Litigation Authority was aware that rules had been broken, yet failed to take retrospective action based on the strength of the evidence that he had disclosed to it in 2013.

The actions taken by the trust, assisted by Hempsons and the NHS Litigation Authority from January 2007 to December 2013, clearly indicate that the trust was covering up a clinical incident and its cause. With so much time having passed since my constituent first exited the operating theatre in the summer of 2006, I hope that today the Minister of State will be able to afford Mr Hawkins guidance and support in this matter, and finally bring to some closure what has been a dreadful episode for my constituent.

--- Later in debate ---

[Stephen Barclay]

The hon. Gentleman will appreciate that the events took place more than 11 years ago and that it is, therefore, not for me to comment on what the trust knew at that time or their actions accordingly. I think we all, across the House, recognise that resolving issues without recourse to litigation is preferable, where possible, to lawyers being involved at an early stage—and I say that as a former lawyer. That is why the Government seek to improve how complaints are handled, including improving the regulation. The Care Quality Commission now rigorously inspects all trusts and primary and adult care providers, and a duty of candour—a new protection for whistleblowers—encourages staff to speak up for safety and hence fosters greater transparency. There is also the development of a culture of learning, through patient safety collaboratives and the national Sign up to Safety campaign, and last April the healthcare safety investigation branch became a fully operational and independent branch of NHS Improvement, to investigate serious incidents in the NHS with a strong focus on system-wide learning.

[Dr Poulter]

I do not wish to distract from the main purpose of the debate, but my hon. Friend makes an important point about a culture of openness and transparency in dealing with complaints. How does he feel that the recent High Court judgment about a doctor being struck off by the General Medical Council might play into doctors’ and other healthcare professionals’ willingness to engage with such a culture? Might it be inhibitory, in that they would be concerned about the impact on their future careers of being open and willing to own up to mistakes?

[Stephen Barclay]

As a former Minister, my hon. Friend knows that there are conventions regarding Ministers of the Crown commenting on court judgments. The Secretary of State has already made clear his position on that matter, and this debate on a specific constituency issue is not the forum for moving beyond that scope.

It is important for us all that we improve the handling of complaints. In a system as large as the NHS, we all recognise that, with the best will in the world, things will go wrong and mistakes will be made. The latest Care Quality Commission annual “State of Care” report, published in October 2017, recognises that the vast majority of patients get good care and that many parts of the NHS have improved thanks to the hard work of the staff. The key issue that the hon. Member for Denton and Reddish has rightly brought before us today is how we learn from things going wrong and how, when a patient thinks something has gone wrong, the issues are aired and resolved.

I commend the hon. Gentleman for securing the debate, notwithstanding his elevated position in the shadow Cabinet, and for ensuring that his constituent’s issues have been aired before the House. The Government are committed to building a learning culture within the NHS that listens to patients and relatives and learns from mistakes, so that patients do not suffer avoidable harm. The Secretary of State deserves great credit for his championing of patient safety as a specific issue within his portfolio. We are also working to improve the complaints handling system so that it is more responsive and joined-up between organisations. I hope that the improvements that are in place will help Mr Hawkins to get some closure on the matters we have debated today.